At last I come to the point where I can explain how the data will be used. The first step in the process will be to wait. It will take some time to build up a database large enough to provide us with useful results. Common problems will build up a strong dataset sooner than rare problems.

Of course, there won’t be a simple collection of ailments linked to treatments. For any given ailment, a variety of treatments will be used depending upon the specifics of the case. Nevertheless, we will be able to start off drawing some useful conclusions. Let’s start off with a simple example: a broken leg. We get lots of broken legs showing up in emergency rooms. They range in complexity from simple clean breaks to compound fractures to smashed legs. For starters, though, when we have little data, we’ll begin by lumping all broken legs together. For each case of a broken leg, we have two critical pieces of information for our first estimate: the total cost of the therapy, the degree of success of the therapy (how much QALY the patient subsequently enjoys). By the way, this second value—the success of the therapy—cannot be determined anytime soon after treatment. We will need to wait some time in most cases. Cancer cases may well take years before we can assign QALY values to them. The database will not be of any use for the first two years; after that, we should be able to start getting SOME useful information out of it. After ten years, we should be able to get a lot of useful information, but some issues will take 20 years to satisfactorily resolve.

So for every combination of ailment and treatment, we use these two values (total cost of treatment and QALY result, to calculate a net cost-benefit number in terms of how many dollars we paid, on average, per QALY.

This number, the number of dollars paid per resulting QALY, is our fundamental metric for the value of any therapy. Our goal is to maximize the benefits obtained by a limited number of dollars, so we will make all of our determinations based on the value of that number as established in the database.

No two cases are alike; every broken leg differs from every other in many different dimensions. This problem does not prevent us from drawing useful conclusions; it only makes those conclusions less applicable to any given case. Initially, we’ll have to lump all the data on all the broken legs into one big group, yielding a single cost-benefit value for all broken leg treatments. The trick is that whatever final number we get for the average will have a broad range of uncertainty. Thus, the final criterion will not be “$X per QALY for treating broken legs”—it will be “$X plus or minus $Y per QALY”. This number will be what comes out of the computer.

But we’re not going to simply accept numbers coming out of the computer unquestioningly. When a result comes out of the computer, it must still pass one more hurdle: expert approval. We’ll need to set up a deliberative body that vets the numbers coming out of the computer. This group must include a broad array of experts in its makeup: doctors with direct clinical experience; medical academics and researchers; statisticians; representatives of health insurance companies; and a few token Scrooges who are charged with protecting the taxpayers’ money.

I expect this group to be more than a committee; it will likely need its own staff to examine the particulars of each issue. For something of this much importance, we can afford to set up a department within the NIH devoted exclusively to this vetting process.

Each number that comes out of the computer is presented to the vetting department, along with all the supporting data on the number of cases, variability in the ailment in question, differing kinds of treatment, and cost considerations. The committee has just two options: it can accept the number as a sound basis for policy, or it can send it back to wait for more data. A common reason for sending back a number would be excessive variability in treatments. In the example of broken legs, the committee might well defer accepting a number until it could be broken down into subclasses based on the severity of the injury. This would decrease the uncertainty value of the final results.

None of this will have any application in the early years. The scheme will build up a set of results for many different conditions and treatments, and this process will take several years before we have built a set that’s large enough to be useful. But eventually we will have enough data to start using it effectively. Here’s how we’ll use it:

Remember, our final results will be a table of conditions and treatments and the cost per QALY arising from that treatment of that condition. The next step will be to sort that table by the cost-benefit ratio of the treatment. This yields a sorted list of conditions + treatments and cost-benefit values.

The next step is to estimate the net cost of treating each such condition, weighted by frequency of occurrence. In other words, we use existing data to estimate how many such cases arise per year, and multiply that by the average cost per case. If we know that on the average year we’ll see 11,000 compound fracture injuries to the leg, and that the average cost of treating each case is $20,000, then we’ll calculate that the total cost of treating all those cases will be $220 million. We carry out this calculation for every entry in our table.

Every year we go to Congress and present them with this table and ask them to draw a line anywhere they want. Anything above that line (less cost-effective) will not be paid for by the government. Everything below that line (more cost-effective) will be treated at government cost. We use the cumulative cost data in the table to tell Congress how much this should cost. Congress debates just how generous it wishes to be, and then writes the final value into the budget.

Now we have a rational basis for providing health care. All the condition-treatment pairs that are below Congress’ line are automatically approved for treatment. If you show up at the hospital with that condition, you will be treated and the Feds will pick up the bill.

By the way, this process could also be used for preventative health care such as annual health exams. While we would not be able to rigorously measure the actual value of such preventative measures, we could indirectly measure that value by measuring costs arising from diseases that would be likely to be detected more quickly in health exams. A similar process could be used for preventative medications such as aspirin as a preventative for heart attacks.

But what happens if you have a condition that does not fall below the magic line? If you have no health insurance, you die. Presumably the American people will be willing to fund generously enough to keep the mortality rate of the indigent to some reasonable level. However, you can also purchase health insurance that, in effect, raises your limit. The benefits of health insurance are defined in terms of the same cost-benefit numbers that come out of the national database.

For example, suppose that the Feds cover all conditions costing less than $3,000 per QALY. You could then purchase insurance covering you for conditions up to $5,000 per QALY; if you’re willing to spend more money on your insurance payments, you could get coverage for conditions up to $10,000 per QALY. (Of course, deductibles could still be written into the insurance contract.)

With the passage of time, the national database grows and the precision of our estimates grows. We will be able to estimate costs for treating specific medical conditions with ever greater fineness. That will take time, of course.

Believe it or not, this (I think) concludes this series. I’m sure that many objections will arise; if significant holes are pointed out, I may write up a sixth essays to patch up the mistakes.

This has already been done. I disagree with a lot of your conclusions about the validity and ability to collect data as well as our ability to interpret it properly, but an analysis similar to yours will be and has been the basis for a number of public health care plans around the world and even in this country ( I believe that they have done something like this in Oregon or Washington but for some reason it wasn’t very successful there - perhaps someone else can fill in the gaps).

As a clinician I am always leary of a governmental agency using numbers in this fashion. The problem is that there may be no truly significant difference between item number 467 on our list of treatments that we deem cost effective and item number 468 which falls on the other side of the line in this years budget and won’t be paid for. These analysis are based on population statistics and will never be able to accurately account for each individual circumstance and the rapidity of change in the medical field. Lots of people will fall through the cracks.

Don’t get me wrong. I think something of this nature is essential if we are to control costs and get everyone insured. I just htink everyone needs to be ready to accept the fact that there will be problems with this approach.

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For every complex problem there is a solution that is simple, obvious,.... and just plain wrong

I don’t claim any great innovation here; the only significant new idea I am proposing is the regular, continuous, and complete gathering of all health care data, as opposed to focused clinical studies. Most of that data already exists locally: hospitals keep careful records of costs, doctors keep careful records of lab tests and treatments. What I’m proposing is more a matter of nationwide integration than anything fundamentally new.

But the heart of your objection, I think, while sounding fair and reasonable, is fundamentally at odds with a concept central to our political system. I’ll express the two competing ideas in bumper-sticker form:

A nation of laws, not men

versus

Treat every person as an individual, not a number.

These two ideas are both admirable, yet they are fundamentally in opposition. The first requires us to replace the idiosyncratic and capricious judgement of individuals with regular, universal laws applying to everybody. The second requires us to rely on fine-tuned judgements of each individual case, judgements that can only be made by individuals.

I think we can draw some useful illumination by comparing the relationship between doctor and patient with the relationship between accused and judge. We believe strongly that the doctor should be the sole judge of what is best for the patient; imposing rules derived from mass experience denies the individuality of the patient and will ultimately lead to many errors. Yet look how badly that reasoning works when we apply it to the closely analogous relationship between judge and accused. Should we allow judges to decide guilt or innocence, and punishment upon the accused, with no externally imposed rules to control the judge’s actions? Of course not! We all know that there’s a lot of variability among judges, even though they are all highly trained professionals. If we left our justice system to the exclusive judgement of judges, then we know that there would be lots of injustice. Yet you are arguing that we should leave our medical system to the exclusive judgement of doctors.

Obviously, there are two huge differences between the two systems. In the first place, the doctor is making two different decisions, only one of which is of concern to anybody else: 1) a choice among a number of competing treatments; and 2) a determination of what treatments are cost-effective. The first choice, if it has no financial impact (say, between two treatments that cost the same), is nobody’s business but the doctor’s and the patient’s. But the second decision is certainly fair game for public participation: the public is paying for it!

The second huge difference is that the judge’s decision is made in an adversarial mode. There’s the prosecution and the defense, both arguing it out in front of the judge. The judge’s primary task is an either-or choice between one side’s position and the other side’s position. In the doctor-patient relationship, there’s no “anti-doctor” sitting next to the doctor, arguing the case against any particular treatment.

Nevertheless, there is a basic principle at work here that is offensive to doctors but nevertheless appropriate now that the doctor-patient relationship is evolving from a strictly private relationship to something that is more public in nature. That principle is “trust the rules, not the professionals”. Professionals everywhere hate it. Programmers really hate the idea of code review, in which their code is reviewed by somebody else. Aircraft pilots hate the idea that there’s a cockpit voice recorder recording everything they say and do for later review. Judges hate the idea of higher courts that sit in judgement of their decisions. Now doctors are getting sucked into the same demeaning situation, and they don’t like it one bit, and I don’t blame them. But the world is growing ever more tightly integrated, and doctors might as well shrug their shoulders and get used to it. They already face this problem in the constant threat of lawsuits. A more precisely defined system will replace the tyranny of litigation with a less traumatic system that we can expect will be more fair.

There’s also the problem of mistakes. Every rule-based system makes mistakes. A great example of this is the Three Mile Island accident, in which there was a nasty conflict between the regulations about how to operate a power reactor and the judgement of the experts running the plant. If they had done it solely by the book, there would have been no accident. Had they relied solely on their own professional judgement, there would have been no accident. But their attempt to apply their own judgement within the bounds established by the rules led to a disaster. These kinds of things happen all the time. Our legal system lets plenty of guilty people get away, and sometimes punishes innocent people. But the big difference between a rule-based system and an expert-based system is that the rule-based system is heuristic. When it produces bad results, you can analyze what went wrong and change the rules. When an expert produces bad results, you can either revoke his license—throwing away a great deal of valuable talent—or you can make him pay in a lawsuit. In either case, there’s not much reason to believe that the problem has been solved and will henceforth be prevented.

Lastly, you raise the objection of arbitrary dividing lines. This happens all the time in the legal world, and we learn to live with it. If you’re caught with X grams of some illegal drug, it’s a felony, but X-.01 grams is only a misdemeanor. If you’re caught with X BAC while driving, you lose your driver’s licence—but a BAC of x-1% is only a misdemeanor. Earn $X of annual income and fail to file an income tax return, and it’s no big deal, but $X+1 and the IRS is all over you. The world is full of arbitrarily drawn lines that we use to make major decisions. There’s no reason why the medical world should not live by the same rules. Indeed, many medical decisions are based on even more arbitrary factors. We already have arbitrariness in our medical system; my proposal would replace the capricious arbitrariness of the current system with a transparent and agreed-upon arbitrariness.

Chris I wish I had all the time that you do to right a proper response. Unfortunately I don’t, so I’ll just address two items which I think are important.

1) You have far too much confidence in the ability of retrospective population based analysis to come to valid conclusions and replace traditional placebo controlled studies. Retrospective population based studies are cheap and dirty method of medical research. they are easy and inexpensive, but they are fraught with problems. The problem is the uncontrolled variables and bias that exists in every one of these studies. For virtually every human trait or disease you want to study there are numerous traits and risk factors that travel in tandem. Sorting them out when you are not randomly assigning individuals to the treatment and control groups is very difficult. A study which retrospectively looked at the utility of using Statins in patients would have to deal with a number of confounding variables. For example, the group of patients not taking statins could not be on statins for many reasons. Some of them may be non-compliant patients. Non-compliant patients are often more likely to make other poor choices - smoking, drinking, over eating, risky sexual behavior, reckless driving, low level of education etc. So if the death rate among the non-statin users is higher is it because they are not on statins or is it because of one of these coexisting risks that will be occur at higher rates in this group. That’s just one example, but every single population based study has to deal with this problem since individuals are not randomly assigned to the treatment and control groups. Population studies are useful for helping us decide where to put our research money ( ie. what questions should we try to answer with a double blinded study) not our treatment money.

2) The second issue is a bit more personal. The way you describe the physician of the future is much more of a bureaucratic technician than an independent thinker and problem solver or healer. I am trying to separate my innate revulsion to this idea from the benefits of your approach to come to an unbiased conclusion as to whether this argument has merit and the thing I keep asking myself is this. Why would anyone in their right mind become a doctor under this system? Young people go into medicine for the personal rewards that come from using their acquired knowledge and experience to make a difference in people’s lives. That will change dramatically when a physician becomes nothing more than a data collection and order processing clerk. This could be a real problem. Maybe you’re right, and maybe this is inevitable, but I’m not sure I would want a person taking care of me who was drawn to this kind of work. When medicine becomes completely"cookbook” all the good chefs will find something else to do.

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For every complex problem there is a solution that is simple, obvious,.... and just plain wrong

Macgyver, regarding your first point, the many flaws of population-based studies, let me remind you that this country makes its most important decisions using exactly this method. We don’t use a carefully selected random group of people; instead, our sample is self-selected, which everybody agrees is surely one of the worst ways to get a representative sample. How is it that we can justify the use of such a patently misleading way to make these decisions? I don’t know, but everybody agrees that elections are a better way to choose our leaders than properly prepared scientific studies.

Therein lies the trick: if you include ALL the data, instead of a representative sample, then the results you obtain are necessarily correct. If the sample size is equal to the population size, then the sample is not merely representative of the population—it IS the population! It’s pretty hard to get wrong answers when your data is equal to the totality of the phenomenon.

Of course, there’s a nasty catch with this line of reasoning: we are breaking that big sample up into subgroups that I claim to be representative of individual cases. If we analyze broken legs in terms of degree of injury, and age and gender of the patient, and then apply those results to all patients meeting those criteria, we still run into problems because patients differ in many more ways than that. My defense here is that these results are still better than what we have now, and with the passage of time, and the accumulation of more data points, we can improve the fidelity of our matching criteria.

I appreciate your second argument; it is indeed a fundamental plaint that we all have about a society that grows ever-larger and ever more formal. Wouldn’t it be so much nicer if we could go back to small-town practice where one doctor knows and cares for everybody, and provides truly personalized care for each and every patient? Wouldn’t it be nicer if there weren’t all those lawsuits that force doctors to overtest patients merely to cover their asses legally? Wouldn’t it be nicer if airplane pilots could just use their judgement and experience and fly in whatever way they wanted, without having all those rules and regulations governing their every decision? There was a time when an airplane pilot was considered one of the elite of society, possessed of skills truly unique; nowadays, they feel like glorified bus drivers. Or how about judges? Wouldn’t it be nicer if we had local judges with complete autonomy, people who knew everybody in the community and could render justice based on personal familiarity with each and every person who comes before them? And why should we burden these judges with the appellate system, where their every minute decision is scrutinized and criticized? And soldiers—why do we burden them with rules of engagement? We put these people in dangerous situations, and then paralyze them with rules and regulations about exactly when they can use their weapons in self-defense. Or police—isn’t it ridiculous to put a person through all that training and then treat them like an idiot by specifying all sorts of details about what they can do, cannot do, and must do. If a policeman fires their weapon, they are immediately removed from street duty, as if they had done something wrong. And woe betide the poor cop who makes a split-second decision and unintentionally kills a criminal who turns out to be unarmed! Everything a cop does is subject to critical review and serious punishment for error. A cop can be sent to jail for performing duties in a way adjudged to be incorrect. Wouldn’t it be nicer if we just trusted cops to do their jobs as they see fit?

Despite these many insulting impositions upon their professional judgement, we still manage to find plenty of judges, pilots, soldiers, and police.

I’m sorry Chris but the very type of error I gave an example of will not be corrected by shear numbers. If a particular group you are looking at has other accompanying/confounding traits it won’t matter whether you look at 1,000 or 1,000,000. Here’s another example. In a recent retrospective study individuals who consumed a daily vitamin were found to have lower rates of diabetes. The conclusion the author made was that vitamins reduced one’s risk of diabetes. Maybe, but since controlled studies have not yielded the same results we have to look at this critically. People who take vitamins may also be more likely to take better care of them selves in general. Most likely they exercise more, eat better and weigh less. It won’t matter how many people you have in your self selected population analysis, you will repeatedly come to the incorrect conclusion that vitamin intake is a direct cause of the reduced diabetes risk when in fact it is simply a co-occurrence in that both conditions are linked to better eating and exercise habits. You can include the entire country in your analysis and the results will NOT be “necessarily correct. They will be conclusively wrong. There are ways to go back and correct for some of these things but these corrections always work on the assumption that we are so smart that we know what to correct for. Unfortunately we’re not that smart.

As far as always being able to get people to take a job no matter how degrading you make the job, you missed the point. I don’t doubt that you can always find someone willing to sign up for a job where he/she gets to put the MD after their name, but you won’t get the same people you are currently getting. Anyone who thinks otherwise is fooling themselves. I am an Internist. When I went in to training several decades ago many of the smartest students chose Internal medicine. The diagnostic challenges were a draw to anyone who was smart and liked a good intellectual challenge. Over the years a number of things in medicine have changed not the least of which is the huge hassle factor from insurance company oversight. This has affected Internists more than others because we and family practitioners as well as pediatricians play the most central role in determining the kind of care people receive. We are not just “Primary Care Providers” we are the “Primary Decision Makers”. The result has been that over the past 10 years applications by American medical school grads to Internal Medicine programs has dropped by 50%. ( Caution: This is a retrospective analysis so my conclusions may be faulty). To your credit, your prediction is correct however. The spots did not go unfilled. The problem is that these challenging jobs are now being filled by foreign medical grads. Some of these people may be quite good, but if you could choose you doctor from a group that graduated in the top of their class or from a group that graduated around the middle and was forced to go abroad and study in a foreign medical school who would you choose? The best and brightest learn quickly. If you make this job less desirable and take away the very things that attract the best students you will have to settle for something much less.

The next time you get sick would you rather put your life in the hands of an imperfect but bright and engaged individual, or would you prefer we place you in the capable care of “Joe Sixpack” and a computer full of “necessarily” correct orders?

There were some interesting essays about Evidence-Based Guidelines in Health Affairs 2005 Vol 24 Number 1. It can be accessed for free at Medscape.com (you have to sign up for it).

Evidence based medicine is a good thing. It provides a set of guidelines arrived at by a group of physicians who have reviewed the accumulated studies on a particular issue. However, evidence based medicine is different from what Chris is proposing in two important ways. First it usually relies on an analysis of multiple studies from different sources to come to a consensus. Chris wants to distill EBM down to a nearly automated process based on a retrospective analysis of data irrespective of prior medical practices and without the safety of controlled studies to confirm their conclusions. Secondly, evidence based medicine in its current form is used only to suggest guidelines for physicians to refer to. Chris on the other hand seems to want to give the powers that be the authority to dictate to the physician how he must treat a given patient with little latitude. These are very different concepts and Chris’ ideas are begining to sound a bit Orwellian I think.

I think that you’re approaching this as a one-shot deal in which the results are determined once and then are engraved in stone for all time. I’m seeing this scheme as an ongoing process. So let’s take that vitamin study you cited. In the first place, we wouldn’t do it with a study. We’d look at all the people in the country who take vitamins. Then we’d divide them up into groups based on such things as diet, exercise, age, and so forth. Then we’d be able to apply those group experiences to individuals. If we have an individual who’s overweight, eats at McDonald’s, and whose primary exercise is using his thumb to change TV channels, we don’t compare him to the people who are slim, who run a mile every day, and eat nothing but organic foods. We compare like to like. Hence, to determine the likelihood that this vitamin will be of value to this particular patient, then we look at all the people who are like him—of which there are millions. We look at those who took the vitamin and those who did not take the vitamin. The results that we get are going to be a much better fit than ANY clinical study, because they’ll be more precisely matched to the individual patient. Clinical studies are blunderbusses—they tell us how any particular treatment will work on the general population, but when it comes to making useful predictions for individuals, they only work well with “general population patients”. As soon as you start applying them to individuals, you get tremendous variability. That’s why you need to get lots of data for lots of very different patients.

But let’s suppose that my scheme starts off with lousy data and predicts that a vitamin will help fat people avoid diabetes when in fact it has no value. So physicians, using this faulty data, start recommending it to their patients. Some take it, some don’t. After a few years, we’ve built up lots of data showing that it doesn’t work for fat patients. The data changes, and so the recommendation changes. The problem solves itself.

That’s a crucial distinction between my scheme and the current system: it is ongoing and continually updates itself with new data, permitting ever finer discriminations between patients. Right now, we have, for many conditions, a list of treatments that sometimes work and seldom do harm, so we start the patient off on the treatment with the best combination of efficacy and minimal side effects. We know perfectly well that that treatment won’t help all patients, so we let it run for a few months and see what happens. If it doesn’t work, we move on to another treatment. This can go on for several years. In a few decades, we might well be able to determine that Patient A should start off with Treatment X, while Patient B, who is somewhat older, has blood type O, a history of smoking, and has had children, should start off with Treatment Y. Don’t you think that would work better than our current system of informed guesswork?

You’re right that reducing professional discretion chases away the top talent. This is a problem common to all professions, and many professions are acutely aware of the problem. Teaching suffers particularly from the problem: good teachers often lose patience with the educational bureaucracy and change careers. But there’s a counterbalancing benefit to the more bureaucratic approach: you get less damage from the bad apples. A bad doctor kills people, and it happens all the time. Doctors make bad judgements and people die. Occasionally those bad judgements are due to incompetence. Sometimes they’re due to overwork, or a physician having a really bad day. More commonly, they’re due to incomplete knowledge about a complicated problem—how can any physician keep up with EVERYTHING that might impinge upon a crucial medical decision? And it’s all that uncertainty that makes our health care system so expensive, so inefficient, and so unproductive.

The numbers coming out of this system do not replace the judgement of the physician—they bolster it. They provide the physician with both guidance and protection. A physician would still be allowed overrule the quantitative results and apply their own judgement—and if the case resolved well, then there’d be new and interesting data for the dataset. If the case resolved badly, then the physician would be liable for the consequences of the error—just as physicians already are under the current system. The big difference is that, if a physician adheres to the guidelines, there’s no legal case against them. Lots of litigation doesn’t happen when there are more precisely established and justified standards. Whenever you have high-stakes issues with few defined standards, you’ll have lots of litigation and second-guessing. You can’t make the hassle go away. Either you live in thrall to the lawyers, or to the standards. Lawyers and juries can be really arbitrary; professional standards, while onerous, are not arbitrary. You can’t evade liability when things go wrong. But you can at least establish clear standards that protect you when things do go wrong. Which professional regime would you rather live under: one that makes decisions by juries, or one that makes decisions by quantitative methods?

I didn’t read your second post before writing the previous one; let me now respond to that one. Here’s the crucial quote:

Chris on the other hand seems to want to give the powers that be the authority to dictate to the physician how he must treat a given patient with little latitude.

The primary purpose of this scheme is to determine what will be paid for, not what must be done. If the physician is willing to carry out more expensive treatment out of their own pocket, that’s just fine. The issue here is not the demand of The All-Powerful Computer that the meek little physician do its bidding; the issue here is that the physician is demanding to be paid for their labor, and the people who pay are being asked to “Trust me, I know what I’m doing.” If there’s anything we have learned from this kind of thing, it’s that you can trust the vast majority of the professionals, but there are always a few idiots who screw things up for everybody, and the amount of damage they can do is way out of proportion to their numbers. Look at the financial disaster that is unfolding all around us. Do you really believe that it can be blamed on an entire class of ruthless financiers who took huge risks and, having failed, are now demanding to be bailed out? Yes, there surely were some such people, but it should be obvious that outright venality played a small role in this disaster. Yet a few venal financiers, combined with a lot of merely irresponsible financiers, combined with the great majority of insufficiently cautious financiers, managed to bring our financial system to the brink of collapse, and now the taxpayers are forced to pay gigantic sums to clean up the mess they have made. In the same way, it only takes a few unscrupulous physicians to undermine public trust in the health profession. In the vast majority of cases, you really can trust the physician to do what’s best—but its those few other cases that determine everything.

A really good example comes from the airline industry. We all know that airplane crashes are ridiculously low in probability. Yet they are so corrosive to public trust in the industry that it (along with the government) has evolved elaborate mechanisms to prevent accidents. These mechanisms are procedural and regulatory, and they impose onerous burdens upon the pilots.

So there are two justifications for this system: first, to justify the expenditure of public funds for health care for indigent citizens; and second, to provide a means to reduce the high costs of ‘defensive medicine’. A physician must follow the guidelines while treating patients whose bill will be picked up by the government. If the patient is paying his own bill, then there is no requirement to obey the guidelines. The second justification is legal protection: if you adhere to the guidelines, you cannot lost in litigation if things go wrong. I see this as a big advantage for physicians.

About 75 million Americans have multiple chronic conditions at an annual cost of nearly $1.4 trillion.

Half of you reading this column may know what we mean by chronic conditions because you have one or more, such as hypertension, cholesterol disorders, respiratory diseases, arthritis, heart disease, diabetes, cancer and Alzheimer’s disease. Research has shown that as individuals accrue more chronic conditions, health outcomes decline and health care costs increase.

It is not uncommon for health care providers to examine and treat patients with five, six or seven chronic conditions. As an example, it has been noted that close to one-quarter of Medicare beneficiaries now have five or more chronic conditions and see 14 different physicians on average each year, make 37 office visits and have 50 prescriptions filled. For the individual patient this can be daunting, and it is easy to foresee drug and disease interactions occurring without effective care coordination and case management.

Indeed, the lack of care coordination is the single biggest factor preventing individuals with multiple chronic conditions from receiving timely, safe and effective health care. So what can we learn by understanding our changing demographics to improve the health care system?

First, we need health care professionals who can coordinate care. Primary care physicians who have largely performed this function in the past are increasingly in short supply. They now represent only one-third of all physicians, with very few graduating medical students aspiring to go into primary care fields.

Massachusetts’ recent experience with universal health coverage has taught us that providing health insurance doesn’t ensure access; you still need physicians who are available to see patients. Payment reform for primary care providers and loan repayment programs to incentivize a new generation of primary care providers need to be part of the solution.

Second, health care providers need tools such as evidence-based guidelines to coordinate care. Unfortunately, in many cases, clinical trials exclude individuals with multiple chronic conditions, and existing guidelines on chronic conditions fail to take into account other co-occurring conditions. Tools such as health information technology would also support care coordination, but adoption of electronic health records remains in the 10%-20% range.

We need renewed commitments to health care services research to learn how to care for individuals with multiple chronic conditions and help us figure out what works and what doesn’t work for different populations. And there needs to be a business case for providers to adopt electronic health records.

Third, we need a cultural change in how this country looks at health. Building upon existing efforts, we could expand our national public-private health awareness campaigns focused on health promotion and disease prevention. This should include the government as well as the business, education, health care, and food and beverage sectors so that incentives can be created for individuals to make healthy lifestyle choices. The default option must become the healthy option.

Finally, we need to accelerate research and dissemination of self-care management techniques so individuals can more confidently and effectively manage their own health.

There are clearly major strides that need to be made for this country to become a healthier nation. The U.S. Department of Health and Human Services recently launched a workgroup on individuals with multiple chronic conditions to focus on improving the health status of this population. The experiences of this growing population should provide some clues as to how to improve the health of our nation.

ANAND K. PAREKH, MD, is a native of West Bloomfield and a graduate of Birmingham Detroit Country Day and the University of Michigan who serves as deputy assistant secretary for health (Science and Medicine) in the U.S. Department of Health and Human Services. He serves on the Board of Governors of the U-M School of Public Health Alumni Society. Contact him by e-mail through .(JavaScript must be enabled to view this email address).

cut out the private insurance companies, ensure all and save half as much because as things stand with private insurance we got nearly 50 million uninsured and we spend twice as much per capita as the rest of the developed world who have a single payer program.

on a somewhat side note, I saw a poster of a cop poking a homeless dude sleeping on a bench. The caption was:

Q. What’s the difference between a homeless person and a prisoner of war?
A. Per the Geneva Convention a POW has a right to food, shelter and medical care.

The primary purpose of this scheme is to determine what will be paid for, not what must be done. If the physician is willing to carry out more expensive treatment out of their own pocket, that’s just fine. The issue here is not the demand of The All-Powerful Computer that the meek little physician do its bidding; the issue here is that the physician is demanding to be paid for their labor, and the people who pay are being asked to “Trust me, I know what I’m doing.” If there’s anything we have learned from this kind of thing, it’s that you can trust the vast majority of the professionals, but there are always a few idiots who screw things up for everybody, and the amount of damage they can do is way out of proportion to their numbers. Look at the financial disaster that is unfolding all around us. Do you really believe that it can be blamed on an entire class of ruthless financiers who took huge risks and, having failed, are now demanding to be bailed out? Yes, there surely were some such people, but it should be obvious that outright venality played a small role in this disaster. Yet a few venal financiers, combined with a lot of merely irresponsible financiers, combined with the great majority of insufficiently cautious financiers, managed to bring our financial system to the brink of collapse, and now the taxpayers are forced to pay gigantic sums to clean up the mess they have made. In the same way, it only takes a few unscrupulous physicians to undermine public trust in the health profession. In the vast majority of cases, you really can trust the physician to do what’s best—but its those few other cases that determine everything.

A really good example comes from the airline industry. We all know that airplane crashes are ridiculously low in probability. Yet they are so corrosive to public trust in the industry that it (along with the government) has evolved elaborate mechanisms to prevent accidents. These mechanisms are procedural and regulatory, and they impose onerous burdens upon the pilots.

So there are two justifications for this system: first, to justify the expenditure of public funds for health care for indigent citizens; and second, to provide a means to reduce the high costs of ‘defensive medicine’. A physician must follow the guidelines while treating patients whose bill will be picked up by the government. If the patient is paying his own bill, then there is no requirement to obey the guidelines. The second justification is legal protection: if you adhere to the guidelines, you cannot lost in litigation if things go wrong. I see this as a big advantage for physicians.

Chris, I’m sorry I didn’t respond to this sooner. Your posts usually address a number of issues and take time to respond to, and in this managed care world I don’t have as much time as I would like to debate this with you.

First I have to respond to the comment “If the physician is willing to carry out more expensive treatment out of their own pocket, that’s just fine. “. You’re kidding me right? This has to be one of the most cynical comments you’ve made. I will give you the benefit of the doubt and assume this is tongue in cheek. Doctors don’t have deep pockets and can not afford to start paying for their patients medical care every time they disagree with the all mighty powers that be in your scheme. You make an incorrect assumption that the physician is somehow benefiting by ordering these expensive tests. While that may occasionally be true ( ie. a cardiologist recommending a stress test), at least 90% of the “expensive” things I order are done by other physicians. I receive no benefit. If the plan won’t cover them they won’t get done. The statement also exemplifies the very arrogance that worries me so much. I come across this arrogance every day dealing with insurance companies. The only place that its worse is when we have to deal with the government. If you institute a single payor system ( which I believe is necessary) and then give the system the power to decide what course a physician must follow in each and every case I guarantee you that these “recommendations” will become edicts. There will be no flexibility.

You keep claiming that these recommendations will decrease the physicians risk of a lawsuit “if” they follow the recommendations. And there in lies the rub. For every medical decision there are at least two possible paths to take. There usually is no right path and wrong path. Each path has its own risks and benefits. Your database will recommend path A which leads to a successful outcome 51% of the time but a poor outcome 49% of the time. Which ever path is chosen there is a chance for bad outcome, but if the patient for some reason prefers path B which in general is successful only 49% of the time the doctor runs the risk of being sued because it wasn’t the “recommended” path. The doctor is now even more likely to be sued because there it is written in stone that path A should have been chosen. Not only will doctors be sued more often but patients will have fewer choices because physicians will be too scared to deviate from the recommendations.

The recommendations will be considered so all powerfull that any deviation from the edicts will be used by lawyers as grounds for a law suit.

And how will physicians integrate these recommendations. Are they to sit in front of a computer constantly entering every scrap of information and then waiting for the blessed recommendation to pop up on the screen? Currently I have the protocols in my head. It may not be as perfect as a computer but its much faster. If I walk into a room and am presented with a patient that has a CT report showing a 1cm pulmonary nodule I don’t need to look up what the proper steps are to take. That program is in my brain. I call it up instantly and make my recommendations to the patient. If I now have to refer to a set of recommendations that are the new gold standard I will need to refer to this database for every single patient encounter.

The difference between your system and the current system is this. I still have to refer to the literature to see what the latest recommendations are, but those recommendations don’t change on a dime. They are debated among physicians over a period of time until a general consensus develops. Its a bit of a nebulous process because of all the deliberation that takes place. If the recommendation for what to do with that pulmonary nodule changes from “repeat the CT at 3,6 and 12 month intervals” to ” check it in 12 months and then forget about it if there is no change” that shift occurs over time. Under your system there will be an actual date when “the recommendation” changes. That date is something the lawyer can actually look up. If it changes on Sept 8th and I make old recommendation on Sept 9th I’m up the creek. For this reason no physician will feel safe unless he refers to the database for every single encounter. What was good practice in the morning may be bad practice by lunch time.

That process will slow things down dramatically. There’s not as much profit in medical practice as people think. If you decrease the number of patients a doctor can see in an hour from 4 to 3 he will go out of business. Many physicians who are currently using EMR’s have reported that efficencey declined for long periods of time and in many cases never returned to their pre-EMR levels. Your system would most likely slow things down even further. Then again if we don’t have to give patients choices and no longer have to discuss risk/benefit ratios with them that will save some time ;-)

cut out the private insurance companies, ensure all and save half as much because as things stand with private insurance we got nearly 50 million uninsured and we spend twice as much per capita as the rest of the developed world who have a single payer program.

on a somewhat side note, I saw a poster of a cop poking a homeless dude sleeping on a bench. The caption was:

Q. What’s the difference between a homeless person and a prisoner of war?
A. Per the Geneva Convention a POW has a right to food, shelter and medical care.

I disagree, there are good a bad insurance companies out there. The minority of them (typically the large national ones) give the good ones (typically the small regional ones) bad names. Almost everyone in healthcare is in it to make money, the insurance companies, the hospitals, the doctors. Without insurance companies who will look after the other two. And the hospitals and doctors watch the insurance companies.

I think you’re allowing your defensiveness to bias your reading of what I write. Each of your paragraphs is predicated on a misreading of a particular element of my proposal. For example, your first argument, objecting to what you perceive to be arrogance, completely misconstrues the point I made. My argument here is no more complicated than “He who pays the piper calls the tune”. It is economically untenable to have Party A pay for work done by Party B at the latter’s discretion. In every case where that is done, Party A inevitably ends up feeling cheated. And I think it is fundamentally unfair for anybody—including physicians—to expect freedom to make decisions affecting others while evading responsibility for the financial consequences of those decisions. Our society has developed all sorts of extremely complicated mechanisms for matching decision-making power with financial liability. True, there are still plenty of violations of that basic goal, but we all agree that those violations constitute flaws in the system.

You argue that physicians do not order tests to advance their financial interests. I disagree. A great many physicians order tests whose diagnostic value is slight, but they do so to protect themselves against litigation. I don’t blame them one bit—we’ve set up the incentives to induce them to do that. The problem is not with physicians, the problem is with a system that motivates reasonable people (physicians) to waste resources.

So my comment about physicians bearing the costs of their decisions was not cynical—it was presenting the converse of “He who pays the piper calls the tune”. It’s fine with me if you want to call the tune—just don’t expect me or other taxpayers to pay for that tune.

You argue that there will be no flexibility. Let’s differentiate between rational flexibility and irrational flexibility. The former is the freedom to go either way in a close call. The latter is the freedom to do anything in defiance of experience. I think that you’re not sufficiently differentiating between the two. You cite as an example a close call and use the close call as a justification for the freedom to do anything in defiance of experience. Moreover, your argument (and indeed, your entire approach) belies a refusal to accept the role of second moment figures—the uncertainties. Over and over you have argued against the use of first-moment figures on the explicit or implicit grounds that they have uncertainties—yet you refuse to factor in the role of second-moment figures.

Let me apply second-moment figuring to your example. Let’s say we have compiled figures on Treatment A versus Treatment B for a narrowly defined set of conditions. Let’s suppose that Treatment A yields a cost-benefit ration of 0.51 megadollars/QALY while Treatment B is better with only 0.49 megadollars/QALY. You accuse my system of demanding Treatment B every single time, and claim that lawsuits will still arise when Treatment B doesn’t work. But you are ignoring the second moment. The actual statement coming out of the computer will be something like:

At this point you can carry out some simple statistical calculations to determine that Treatment B is X% more likely to yield results superior to Treatment A. You don’t make simple-minded black and white statements here; you make probabilistic statements. All we have to do is write into the enabling law a specification that any medical decision with a greater than 50% statistical certainty of superiority is automatically immune to civil suit. Thus, you have provided the physician with the legal protection required to do the job in a reasonably economical fashion, while protecting the patient from physician error.

You also argue that all this data taking would be too onerous a task. Why should that be? I’m not talking about doctors slaving over their keyboards. We already have pretty good speech recognition and in dedicated applications like this with precisely defined knowledge domains we can surely have excellent speech recognition. We equip doctors with small communications devices (rather like tiny short-range cellphones pinned to their lapels) and the doctor can either direct a short communication to the computer by saying “Computer… blah blah blah” or can record a long statement with “Computer, start logging…” That’s easier and faster than scribbling things down on paper.

Next, you offer the ridiculous complaint that the rapid responsiveness of the system will make physicians vulnerable to fast-changing requirements: “What was good practice in the morning may be bad practice by lunch time.” Again, you’re make the same old black-and-white thinking mistake, failing to take into account the second moment (as well as the vetting process). As data comes in, first moment values will shift (slowly), but second moment values will also change. A dramatic change in first moment values can only happen if the second moment value increases dramatically—meaning that the physician is still protected because of that large second moment.

I’m going to suggest that the fundamental problem you have with this scheme arises from a failure to really grok how statistical analyses work. I’m sure you’ve worked with statistics, but you just don’t seem to get the idea that properly executed statistical analyses produce the uncertainty of a conclusion as well as the conclusion. And uncertainty is really what’s killing us here. It’s uncertainty about the patient’s condition and the remote possibility of something dangerous that forces physicians to cover their asses with tests that have only slight diagnostic value. It’s uncertainty about the best way to handle a case that makes litigation so complex, so expensive, and so prevalent. Right now that uncertainty is resolved in courts of law by juries who don’t understand complicated medical issues, who have to rely on dueling experts, and you can always find experts to support almost any claim in medical science. That uncertainty is impoverishing us. We need to quantify the uncertainty, to nail it down, so that physicians can rigorously justify their decisions even when the outcomes are disastrous.

I want to remind you again that your choice is not between freedom and slavery. Your choice is between the current system, which places you in thrall to lawyers and juries, and my scheme, which places you in thrall to the cumulative experience of physicians all over the country. I know that you would prefer absolute freedom to any kind of thralldom, but given the choice between the courts as your master and the data as your master, which would you prefer?

Once again the devil is in the details. I guess its unfair to be too critical without seeing exactly how this would all work in practice. I am well aware of the fact that the degree of uncertainty accompanies every statistical analysis. Its a standard part of the results in every medical study. Obvoiusly I would need to see exactly how the uncertainty was worked into the whole process.

I am not familiar with the first moment and second moment figuring. I’ve never heard those terms. Perhaps you could define them for those of us hear whop are not statisticians.

A couple of other points. Voice recognition software is not as advanced as you would like to believe. It has been incorporated into some EMR’s, but from what I have heard from fellow MD’s it has been slow and clunky. Few have stuck with it. It also is very inefficient when you need to enter information into specific fields. The current state of the art in EMR’s does not allow for increased efficiency for the majority of physicians ( again my personal hearsay experience only, but information coming from real physicians in the real world) and seems to slow things down significantly for many. Aside from acquisition and implementation costs, this has been one of the biggest obstacles to the adoption of EMR’s by most physicians. I am a true technophile, but have yet to purchase an EMR for these reasons. Your system is heavily reliant on technology. I know you said you would have the government pay for it, but I don’t see that happening. They seem to prefer to use short term incentives and long term penalties to force physicians to pay for these systems at the moment ( see the latest medicare approach to this)

I still can’t see how a physician is going to feel free to make decisions without the computer constantly in front of him. That thing is going to be the bible for the malpractice attorneys who will look for even the slightest deviation as a reason to sue. I’m not convinced you will be able to get our representatives to legislate that away.

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For every complex problem there is a solution that is simple, obvious,.... and just plain wrong